The next case has points of interest in the later history, but the first examinations and early treatment may be passed over briefly. X.Y., æt. forty-two, a steady, sober merchant, closely confined by his business, always of excellent habits, with no possible suspicion of syphilis, was seen first in 1894 in a somewhat advanced stage of tabes, but with no optic or gastric disturbances. His station was very bad, but when once erect and started he could walk without a stick. Girdle-pains very marked; bowels very constipated; some trouble in emptying bladder; several points of fixed sharp pain; lightning pain occasional and severe, but not frequent. He was ordered to bed for six weeks. Galvanism, alternate hot- and cold-water applications to the tender spots, careful massage, and a two-months' course of Brown-Séquard fluid after getting up made a new man of him. Massage and systematic exercise were kept up together for six months. The massage was stopped and the exercises continued, and improvement went on steadily, though the fixed pains kept up in only slightly less severity.
In a year the patient was better in general health, looks, and spirits than he had been for many years before, and remained in good order, except for the daily recurrences of paroxysms of pain of varying but not unbearable severity for two years. He then presumed for a month on his strength, and took much more exercise afoot than was wise, worked late at night over his books, had some additional nervous strain from business worries, and came to Dr. J.K. Mitchell in October, 1898, barely able to crawl with two canes, having lost weight, become sleepless, suffered great increase of pain, and grown so ataxic that he could scarcely walk. This change had all occurred in three or four weeks. He became steadily worse for two or three weeks till he could not stand or walk at all, had cystitis from retention, violent attacks of rectal tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with almost total anæsthesia of the sacral region, buttocks, scrotum, and perineum, inability to retain fæces, while passages from the bowels took place without his knowledge. He found that an increase in the rectal and abdominal pain followed lying down. He therefore spent day and night sitting up. At the end of three weeks there was total paralysis of the legs, and the outlook seemed most unfavorable.
Massage was begun again, strychnia and salol were administered, and a short course of full doses of the testicular fluid was given. A rapidly interrupted faradic current, with an uncovered electrode, to the neighborhood of the rectum, bladder, and buttocks, greatly relieved the anæsthesia, upon which galvanism had no effect; and, in brief, from a state which looked almost as if the last paralytic stage of tabes had suddenly come upon him, he recovered in two months, and is now (July, 1899) better than he was a year ago, before the relapse, and will probably remain so, as he has had his warning.
Without multiplying case histories, it may be said that ataxic paraplegia (a combination of lateral and posterior sclerosis) may be treated in much the same manner. In this disease there is usually much less pain than in ataxia, but greater weakness, and late in its course some rigidity in the extensor groups of the legs; the knee-jerk is preserved or exaggerated. The disease is a rare one. But two recent distinct cases are in my list, and one of these, the one here reported, seems rather more like an ataxia with some anomalous symptoms. The second one had the symptom, uncommon in this malady, of very frequent and excessively severe stabbing pains, and though his co-ordination grew somewhat better, he improved very little in any other way, which, as his trouble was of fourteen years standing, was not astonishing.
The other patient, seen in 1897, was a rancher from New Mexico, thirty-three years old, who had led an active, hard-working, much-exposed life, but had been perfectly well until 1891, when he was said to have had an attack of spinal meningitis, from which he recovered very slowly. Four years later he noticed numbness of feet and weakness of legs, great enough to make it hard for him to get a leg over his horse. Some pains were felt in the limbs, and a constriction about the chest and abdomen, which had steadily increased in severity. Sharp attacks left distinct bruise-marks at the seat of pain each time. Could not empty bladder. Gait feeble, spastic, and paralytic, could not mount steps at all or stand without aid, sway very great. Knee-jerks and muscle-jerks increased, especially on left; ankle-clonus; very slight loss of touch-acuity in lower half of body. Eyes: muscles and eye-grounds negative; pupils equal and active. Bladder could not be emptied; cystitis. Ordered rest, massage, electricity, and full doses of iodide in skimmed milk. In this way he was able to take without distress or indigestion amounts as large as four hundred and forty grains a day. When education in balance, etc., was begun he could not walk without aid, or more than a few steps in any way. In three months from the time he went to bed he walked out-of-doors alone with no stick, and in five months went back to work. The bladder did not improve much until after regular washing out and intravesical galvanism were used, with full doses of strychnia. He was soon able to empty the organ twice a day, and since leaving the hospital writes that it gives him very little annoyance, though as a measure of precaution he uses a catheter once daily. His pains have entirely disappeared, and he is daily on horseback for many hours.
In spastic paralysis, whether in the slowly-developing forms in which it is seen in adults, due sometimes to multiple sclerosis, sometimes to brain tumor, sometimes following upon a transverse myelitis, or in the central paraplegia or diplegia of "birth-palsies," some very fortunate results have followed the careful application of the principles of treatment already described. Absolute confinement to bed is seldom required or in adults desirable, though exercise should be carefully limited to an amount which can be taken without fatigue, and some hours' rest lying down is usually advantageous.
Assuming that the necessary treatment for the disease originating the paralysis is to be carried on in the ordinary way, I will only describe the special forms and methods of exercise I have found serviceable. Whatever the cause, this will be much the same, though in birth-palsies the teaching may have to include groups of muscles and instruction in the co-ordination of actions which are not affected in adult subjects.
First, as to massage: the operator must direct his efforts primarily to the relaxation of the tense muscles, secondarily to the strengthening of the opponent groups, this last being of special importance where actual contraction has taken place. He should make frequent attempts by stretching the rigid groups to overcome the spasm, which in large muscle-masses may be done by grasping with both hands, taking care not to pinch, and pulling the hands apart in the line of the muscle's long axis, thus stretching the muscles. Pressure will sometimes accomplish the same end, and it will be found in certain cases that by kneading during action,—that is, while the patient endeavors to produce voluntary contraction,—the result will be better. Except in the most spastic states, a certain degree of relaxation is possible by effort, though not without practice, and this has to be constantly inculcated and encouraged. After a period varying in length according to the case, lessons in co-ordinating movements are begun. It is best for the patient's encouragement to start with the least affected muscles, so that, seeing the good results, he may be stimulated to persistent effort. The lessons differ only in detail from those given in the list under tabes. Improvement is slower than in ataxia.
In birth-palsy cases not much can be accomplished in the way of education, beyond the attempt by such means as ordinary gymnastics and lessons in drill and walking offer, until the child shall have reached an age when he is able to comprehend what is being attempted. For the imbecile, idiotic, or backward a training-school is the proper place, where mental and bodily functions may both receive attention and where constant intelligent supervision is available.
Many children the subjects of cerebral diplegia are credited with less intelligence than they really possess, partly because they are necessarily backward, and partly because of their difficulty in expressing themselves, the speech-muscles sharing in the disease. These muscles need to be carefully educated, and this might almost be made the subject of a treatise by itself. Each case will require study as to the special difficulties in the way of speech. Some experience most trouble with the vowel sounds, more find the consonants the worst obstacles. Patient practice in forming the sounds soon produce some results; the pupil must be taught, like the deaf mute, to watch and imitate the movements of the lips and tongue.